Provider Demographics
NPI: | 1790704856 |
---|---|
Name: | GANNON, MICHAEL KEVIN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MICHAEL |
Middle Name: | KEVIN |
Last Name: | GANNON |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2979 SQUALICUM PKWY |
Mailing Address - Street 2: | SUITE #203 |
Mailing Address - City: | BELLINGHAM |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98225-1811 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-733-7670 |
Mailing Address - Fax: | 360-647-1901 |
Practice Address - Street 1: | 2979 SQUALICUM PKWY |
Practice Address - Street 2: | SUITE #203 |
Practice Address - City: | BELLINGHAM |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98225-1811 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-733-7670 |
Practice Address - Fax: | 360-647-1901 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-19 |
Last Update Date: | 2021-02-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00021195 | 207XX0005X, 207X00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | GAB23292 | Medicare PIN | |
WA | F23204 | Medicare UPIN |